Years ago, when I was finishing my education as a psychiatrist, I came face to face with one big question: how can I survive the daily confrontation with so much human pain, with sorrow, anxiety, traumas, loss…? I had to find a way to sail safely between two dangerous rocks. On one side there was the risk of being overwhelmed by all the pain and emotion and suffering a burnout myself. On the other side there was the danger of pushing away my own feelings and becoming emotionless, objective, unavailable, untouched by my patients’ pain.
As I was searching for an answer one thing led to another and I found out about Zen meditation. This was the answer to my question. Clearly, meditation was ‘my thing.’ I have learned an awful lot from it. Not only has it formed me in how I work but also in how I live my daily life.
After about ten years I began to feel more and more something like: “This is not fair. I’m keeping the best for myself.” The problem was that I had no idea how to present something like Zen meditation within a psychotherapeutic context. You cannot just start practicing Buddhist meditation in a hospital! And how can you explain to someone who is looking for something to help their pain that you have to sit in silence for a half hour and not expect anything at all from it? The Zen method is not always so accessible.
I began experimenting by weaving into my work some elements of meditation. Then one day some asked me, “Don’t you know about the work of Jon Kabat-Zinn?” I had never heard of him before but quickly went out and found the book—still unread—in the library of the institute where I was working then. I realized immediately, “This will save me ten years of work!” Jon Kabat-Zinn had come out of a similar background and with the same motivations as mine had created a stress reduction program. This program was being used in a hospital and was the subject of thoroughgoing scientific research which was showing it to be an acceptable tool in the medical world. I saw that I did not have to discover the wheel myself. I got in touch with Jon Kabat-Zinn and began an eight week training program based on his work. This was the first of what has now become many.
In the foreword to Jon Kabat-Zinn’s ‘Full Catastrophe Living2’ Thich Nhat Hanh describes the book as a door from the dharma to the world as well as from the world to the dharma3. Jon Kabat-Zinn in his book skilfully succeeds in translating traditional Buddhist concepts in modern everyday language so as to make them accessible to the West. Had it not been for Thich Nhat Hanh’s foreword the Buddhist origin of them might have gone unnoticed to many readers. Thich Nhat Hanh is one of the foremost Buddhist teachers in the West and his few words certainly attracted many Buddhist practitioners to this book and to the application of mindfulness in clinical practice. This work gave rise to a first generation of MBSR teachers.
Jon Kabat-Zinn not only drew on Buddhist tradition but equally on the scientific tradition he was trained in, thus creating acceptability for his work in the world of science and medicine. This attracted many prominent researchers into the field of mindfulness and exciting results came from that research. What we see now is a second generation of mindfulness teachers, many of whom do not have a background in Buddhism at all, but many of them with a very sincere personal practice.
It was a stroke of genius to take mindfulness training out of the buddhist context, but the risk might be that, instead of opening a door to the dharma, it might also close a door leading to the vast richness of that context full of valuable insights and practices.
Many questions that arise in mindfulness research today already have a long history in the Buddhist literature as a topic of discussion and experimentation. To give an example: in the Lotus Sutra a eight year old girl without any meditation experience at all suddenly attains full awakening4. This passage certainly puts on the agenda the question of how much formal practice is necessary (and at that time severely criticised a male chauvinistic monastic attitude).
Some of these texts are very precise using philosophical language, such as large parts of the Pali-Canon. Other texts, such as the Lotus Sutra or the Tibetan Book of the Dead, look very magical and obscure and it is hard to imagine that they contain the roots of mindfulness training.
This article aims at back translating some mindfulness concepts to basic Buddhist concepts (in a movement opposite to Jon Kabat-Zinn’s first move) to make Buddhist literature more accessible to MBSR/CT teachers that are less familiar with the Buddhist traditions and to allow us reconnect with some treasures that are present in our roots,
I allow myself to freely walk through texts and concepts of different buddhist traditions when they seem relevant to this enterprise. I have not the slightest pretension to be comprehensive. But I’ll be glad to give just a taste of it reminding myself of the Buddha saying: Just as the great ocean contains many treasures, but has only one taste, that of salt, so the teaching contains many treasures but has only one taste, that of liberation5.’ .
What Jon Kabat-Zinn did, is in line with a long-standing Buddhist approach called upaya, usually translated as ‘skilful means’. Buddhism is not dogmatic, it is not a creed. It is a practice to be learned and when we read the oldest texts, closest to the historical Buddha, we see that he was an excellent teacher. The Buddha always addresses the person he is talking to in the language and the frame of reference of that person. This yields an extremely rich literature in which the same message is restated in many different ways.
Buddhist teachers after the Buddha have continued that way so you see Chinese Buddhism explained in a very Chinese way and Tibetan Buddhism in a Tibetan style. This accounts for a proliferation of styles, texts and colours.
Jon Kabat-Zinn has done nothing else but continue that tradition and restate the teaching in a way that makes it acceptable to the medical and the scientific world. The development of MBCT again continues the same tradition in reformulating the very same teaching in the language of CBT and adapting it to the sufferings of people with recurrent depression. Further developments will do the same. All this is, very traditionally Buddhist, the product of upaya.
Upaya is an important theme in the Lotus Sutra. It tells the story of a rich man, whose children have a lot of toys to play with. At a sudden moment he realises that the house is on fire and that his children are inside, playing. He calls: fire, fire, but the children think he is just being playful and continue with their toys. In the end the father says: Come outside quickly, I bought you some very exciting new toys. The children run out and are saved from the fire6. This text compares some of the teaching of the Buddha to a toy intended as skilful means (upaya) to save us form suffering without any further intrinsic meaning. It criticises a tendency at that time to become doctrinaire and to lose the real point of the practice.
Research hypotheses are not randomly generated. They always start from an educated guess. For a guess to be educated it can better draw from scientific, clinical and Buddhist resources. This can help us in our research to generate hypotheses that are meaningful and useful and not losing ourselves in studying toys that are intrinsically meaningless.
Four noble Truths
In the Kalama Sutta in the Pali-Canon the Buddha is asked the question: ‘There are so many teachers around, who are we to believe?’ He answers: ‘Do not rely on tradition, scripture, authority or philosophy. Only when you see for yourself that a practice leads to suffering or to wellbeing then you should either reject or accept it.7’
This text illustrates that suffering is at the core of it all. The dharma (the Buddhist teaching) is about suffering and nothing else. No wonder we are drawn to use it in clinical practice!
This is called the first noble truth8: the observation that there is suffering. It is not a dogma. It doesn’t say that all is suffering. It just states the observable fact of suffering.
That also explains why it is generic: it is not about chronic pain, not about depression, not about eating disorders but about suffering. So it is meant to be helpful in all conditions that entail suffering. But of course upaya teaches us to tailor it to the concrete situation of this concrete suffering individual.
Another interesting aspect of this passage in the Kalama Sutta is that the Buddha explicitly presents the dharma as a testable hypothesis. No wonder many scientists feel attracted to Buddhism.
The second noble truth is about the origin of suffering and the third about the ending of suffering due to the ending of its origin. The origin is defined as ‘thirst’ (pali tanha). Thirst in turn originates from feeling (vedana). The link between feeling and thirst is not absolute. Feeling can be prevented from becoming thirst.
To give an example: suppose I fall in love with my neighbour’s wife. In a way nothing is wrong with that, until the moment I definitely want to possess her, when I start to see my life as worthless without her, when I am ready to do anything to …. That is when feeling becomes thirst and we can be sure that a lot of suffering will follow. It is part of the chain of events that led to many a suicide or murder. The same goes for thoughts, feelings, and actions. The moment I identify with them, the moment I pursue them, suffering follows.
The field of mindfulness in modern medicine and healthcare has some very beautiful language to describe this. We speak of stress reactivity and stress response. Reactivity is when thirst takes over, responding is possible as long as a feeling or a thought remains a feeling or a thought and we can remain aware of that without automatically reacting to it. We also call this ‘seeing a thought as a thought, a feeling as a feeling’ metacognitive awareness. Research has shown this to be a key element for mindfulness training to be successful9.
How do we learn that? There is a path, a method. The fourth noble truth is the path leading to the cessation of suffering. The path is known as the eightfold path.
The eightfold path
The eight elements of the eightfold path are not just a simple sequence. They are mutually inclusive. They are called ‘right’ but the Sanskrit term (samma) derives from music theory and actually means harmonious. They are right in the sense of being attuned to each other to form a scale or chord. Since eight elements are hard to memorize they are often summarized into three groups: understanding, virtue and meditation.
Understanding (Prajna) is the entry into the path. It is my experience that people seeking help in medical and healthcare contexts will not be motivated to engage in MBSR/CT if there is not some understanding and a certain trust as to why they should do this and why it should be helpful.
Virtue (Shila) is the element we are probably least at ease with. Isn’t science to be value-free? Mindfulness definitely is not. Without kindness, respect and dignity it is not right (samma) mindfulness at all. These virtues are as well a prerequisite, an element and a consequence of the path. Ethics in Buddhism is completely different from what we are used to in the West in that it is defined in relation to suffering: wholesome is what leads to wellbeing, unwholesome is what leads to suffering. Put in this way even ethics becomes a testable hypothesis. And of course, it is a cornerstone of Western medicine in the Hippocratic Oath and its injunction, primum non nocere.
Meditation (Samadhi) is the third group. Meditation is a lot more popular in the West than it is in the East. We tend to favour it so much that the attuning to the other elements of the path risks getting lost.
Buddhist meditation is an interplay of shamata and vipashyana. Shamata is stopping, calming. It refers to the act of stopping our habitual activities and to bring our attention to something simple. It is integral to Benson’s relaxation response10. The next step is vipashyana: looking, seeing clearly. Such relaxation that occurs during mindfulness training is not an end in itself but it is a step towards looking, toward (metacognitive) awareness. Meditation is the laboratory situation. It is the place where we see our mind at work and learn how to shift from reacting to what presents itself to mindfully holding it and responding appropriately and wholesomely, i.e. with wisdom and compassion.
Right mindfulness (samma sati) finds its place here but the meaning of the term mindfulness has expanded in recent years beyond its original meaning.
It is clear that the whole thing does not end on the cushion. From what you discover in meditation grows understanding. From this understanding grows kindness, this in turns motivates and sustains your meditation practice, which leads to a deepening of understanding, which leads to … The circle is endless.
The hot topic of debate at the time of the Buddha was karma. The word karma means intentional action, behaviour. According to the classic texts karma can be generated by way of body, speech, and thought (in a language that sounds surprisingly familiar to a present day cognitive therapist). The discussion at the time was about the consequences of one’s behaviour. There was among others a nihilistic faction that denied that behaviour had any consequences at all and that life was more or less random. Others espoused a materialistic view, saying that behaviour only had material consequences and no psychological or ethical consequences at all. The Buddha’s statement was very clear: "'I am the owner of my actions (karma), heir to my actions, born of my actions, related through my actions, and have my actions as my arbitrator. Whatever I do, for good or for evil, to that will I fall heir’11 The Buddha held a performance view of self. We are what we do.
The four noble truths thus are a theory of karma. They state that there is a problem and that something can be done about it. Our actions do matter. The formula ends with explaining what there is to be done.
For this reason a criterion for participating in MBSR/MBCT is at least some willingness to examine the whole question of control over your behaviour, to explore the possibility that your situation is not solely dependent on outside conditions, that you can take some degree of responsibility for it yourself. Sometimes a patient comes with the expectation that mindfulness will act on them like some kind of drug. In that case I have to say: mindfulness will not do anything for you, but maybe it can teach you how to do something for yourself. For many patients that is exactly what they are looking for and need the most, a way of participating in their own health and wellbeing. They are happy to finally find what they can do for themselves instead of helplessly relying on outside conditions, drugs and doctors.
Patients with very severe clinical depression or with psychosis may in that moment not be able to take responsibility for their behaviour and in that case, mindfulness training would be contraindicated. But even people suffering from psychosis can be helped and can find a way to get some control over disturbing hallucinations, as the work of Chadwick and his colleagues has shown12.
Mindfulness training in a clinical context turns out to be a very empowering way of working with people. The focus is not on what is wrong but on what is possible. Through working with mindfulness, I came to realise that, as a clinician, I was trained to underestimate the capacities of people. In reading text like the Lotus Sutra I am touched by the all pervading notion that each of us has the potential to become a buddha. Starting a new MBSR or MBCT group is not starting with a group of people with more or less severe problems. Rather it is starting with a group of potential Buddha's. At least, that is the way I see it and I know that is true for many people who teach mindfulness-based interventions.
Present day research has shown us the beneficial effects of meditation (Samadhi). We are acquiring a growing understanding (Prajna) of the mechanisms that underlie it. What is least articulated in the field of mindfulness research is Shila, virtue. The fact that it is less explicit does not mean that it is not present. It cannot be absent.
In Buddhism the fruit of the practice is often designated as prajna-karuna (karuna meaning compassion). From the early beginnings of buddhism the cognitive and the ethical go hand in hand13. Prajna and karuna are not two. They are one. The cognitive and the ethical element form an inseparable whole. In Zen it is said that understanding and compassion are related to each other as the flame and the heat, one being the function of the other. Compassion naturally flows from understanding. Without compassion no understanding is possible.
How can we explain that in more familiar psychological terms’? Metacognitive awareness is a modern rendering of prajna. But I cannot be metacognitively aware of my feelings of sadness, without bringing a lot of kindness to my feelings and myself. It is impossible to be attentive to everything that presents itself without a big dose of kindness. Being honest with yourself like this is being open to everything. And everything is not always pretty.
It can happen that I sit on my meditation cushion in the evening and suddenly remember something really stupid that I did, a blunder I made, something ridiculous…. I was so busy during the day that I totally forgot it. Then in the evening I remember it on the cushion and there is no escape. It would be cruel to become aware of my own stupidity without kindness. We need kindness to make it possible and bearable to have open, receptive attention. I have to let go of judging myself, and reproaching myself for my thoughts and feelings. The act of being cognitively aware is impossible without a compassionate attitude.
In this way awareness needs kindness, but is there also an ethical consequence to metacognitive awareness? The ethics of awareness is not at all moralising. Suppose I am very very angry, so angry that I might kill someone. My anger narrows my consciousness. In this narrowing lies a great danger. When instead of narrowing I can open up and see my anger and hold it without acting on it impulsively, when I can see my thinking and judging at work without taking it to be reality, what will happen?
There will be a larger awareness of the situation, of the interconnectedness of my own motives, of the perspective of the other, of the causes and consequences of my feelings and my choices, and of the suffering of all involved. Compassion springs from the awareness of suffering, in myself and the other, and of our interconnectedness. The murder will in all likelihood not take place. A greater awareness will probably lead to a more adequate dealing with all the ins and outs of the situation.
I discovered that quite often after an 8-week program, participants realise they became more compassionate towards animals. I have heard of many attempts, sometimes with much humour, of saving spiders that would before thoughtlessly be killed. I was at first surprised to hear these outcomes of mindfulness training, especially since none of the Mahayana rhetoric of ‘saving all sentient beings’ is found in the program. But the simple fact of being more aware makes people sensitive to the suffering of even the tiniest animal. I was often touched by that.
It is logical that cognitive researchers approach the field from the cognitive side. It might be wonderful if we also found a way to better conceptualize and investigate the compassionate aspects of mindfulness. The recent work on Compassion Focused Therapy by Paul Gilbert14 offers an example in that direction.
As with many aspects of the teaching, the different Buddhist traditions have adapted their model of student–teacher relationship to the culture in which it is taught. In MBCT, this relationship enters the world of medicine and psychotherapy. This culture shift gives rise to many pitfalls.
Teaching mindfulness, as in the teaching of any skill, is seen as an interaction between the skill in itself, the skilfulness of the teacher and the skilfulness of the student. The teaching must be skilfully tailored to the abilities of the student. The student him or herself is an equally defining element in the relationship as the teacher.
There is no place where a mindfulness trainer’s own practice is more challenged than in the element of inquiry and dialogue. Being a therapist is often an impediment to teaching mindfulness. It is my experience in teaching and supervising mindfulness trainers that therapists and doctors often fall back on their instinct to give advice or be warm and friendly and supportive, sometimes in ways that disempower the person. Mindfulness training instead acknowledges the person’s own responsibility for his or her thoughts and feelings, and for his or her practice.
Inquiry during a mindfulness class is only one other technique to teach mindfulness, just like the bodyscan or the 3-minute breathing space. The common pitfall is to see inquiry as a psychotherapeutic exploration, oriented toward a framing or solution of the problem.
During the process of inquiry the teacher is continuously (although not intentionally) challenged, and it is easy to react instead of to respond. Whether fear comes up or anger or sadness, the teacher attends to it with kindness, without judgment, with an open mind. You accept it as a fact, as the way the trainee experiences his own perspective. You acknowledge the participants perspective as his or her perspective, without having to identify or agree with it.
As trainers, we are called to embody mindfulness. We will notice the tendency of the mind to defend, to console, to agree, to contradict, to react. The group will look at us and wonder: what’s he going to say to this? So by responding without reacting to whatever comes, we become a role model in the process of teaching mindfulness. How we respond is guided by the intention to teach the trainee to attend mindfully to his or her own experience. We accept what students present as their perspective on the world and assist in clarifying that experience.
The first place to learn about inquiry is our own meditation practice. To sit or lie down non-judgmentally and with kindness, attending to what presents itself, is a powerful training. Exactly the same is what happens in inquiry.
This is why It is very hard to teach someone a skill we have not mastered ourselves to some extent. It all starts from our own practice. ‘one teaches out of one’s passion for the practice’, says Jon Kabat-Zinn. Thich Nhat Hanh, in a conference, told the story of a jealous student who asked him: ‘And when wilI I be ready to be a teacher?’. His quick reply was: ‘When you’re happy’. A sobering yardstick and a good measure of motivation for anybody wishing to teach mindfulness.
The Lotus Sutra has some touching advice for any teacher: ‘ [the teacher] should enter the room of the Buddha, put on the robes of the Buddha, and sit on the throne of the Buddha.’ The Sutra explains: ‘Great compassion is the room, kindness and patience are the robes, the emptiness of all Dharmas is the throne’15. The first influence of Zen meditation on my clinical practice was that I learned to see my patients not as disturbed but as suffering. For a psychiatrist this is really a paradigm shift. Compassion is the spontaneous healing response towards suffering. Kindness and patience help us to not automatically react to adverse reactions. Like a robe, they can protect us, even when the process of change is difficult. Emptiness refers to the openness we discover and cultivate in our own practice. It refers to insight into the intrinsically insubstantial, empty nature of all things, that they are not permanent and self-existing. It is the point from where it all starts.
In the vast treasure of Buddhist stories the following pearl can be found.
Zen Master Gutei, whenever he was questioned, just stuck up one finger.
At one time he had a young attendant, whom a visitor asked, "What is the Zen your Master is teaching?" The boy also stuck up one finger. Hearing of this Gutei cut off the boy's finger with a knife. As the boy ran out screaming with pain, Gutei called to him. When the boy turned his head, Gutei stuck up his finger. The boy was suddenly enlightened.16
Just to reassure you: this event never really took place. Zen teachers do not walk around carrying knives, let alone cutting off fingers. These kind of didactic stories, called koans, deliberately and with a great sense of humour, challenge our preconceptions.
This story is (among other things) about manualising interventions. Gutei in his teaching seemed to follow a very simple protocol for his intervention: he just stuck up one finger. But when our little “sorcerer’s apprentice” follows his masters protocol he completely fails. The same behaviour, at least so it seems, clearly does not carry the same meaning. Only when the protocol is broken (symbolized by cutting of the finger) does he realise the point.
The behaviour displayed in this koan definitely is not a protocol to be mimicked in mindfulness training! But when we wonder by what behaviour skillful inquiry could be recognized by an observer, this story warns us to not be overly superficial in our understanding of what is actually going on.
At the centre of all Buddhist traditions are what are called the Three Jewels: Buddha, Dharma and Sangha.
Buddha is originally stands for the historical person. In later years the meaning shifted from the person to what he stands for. Jon Kabat-Zinn sometimes shows a photograph of a large Buddha statue in his talks and suggests to the audience that this is not so much to be understood as representing a deity, but rather a particular mental state, namely wakefulness.
Dharma is the teaching, and the practice. As the history of Buddhism shows, it is in a process of continual reformulation in accordance with the present needs of those in front of us.
Sangha is the community, originally meaning the community of monastics (monks and nuns) and extending to all involved. There is a strong feeling that this is not an individual thing. The group is important. We support each other when we practice together. That is one reason why it is so powerful to teach mindfulness in groups.
There is also the community of mindfulness teachers and researchers. We are a sangha too. My hope is that this sangha, as it grows and becomes more and more rooted in western science and in clinical practice. will not loose all ties with the richness of its ancient buddhist roots. There is still a lot to learn from that tradition,
So I want to end this text, as an offering to this sangha, with a beautiful dialogue between the Buddha and Ananda:
‘Ananda said to the Blessed One, "This is half of the holy life, lord: admirable friendship, admirable companionship, admirable camaraderie."
"Don't say that, Ananda. Don't say that. Admirable friendship, admirable companionship, admirable camaraderie is actually the whole of the holy life. When a monk has admirable people as friends, companions, & comrades, he can be expected to develop & pursue the noble eightfold path17.’
1 Edel Maex is a practicing psychiatrist and zen student
2 Kabat-Zinn, J. (1990) Full castastrophe living: the program of the Stress Reduction Clinic at the University of Massachusetts Medical Center. New York: Dell Publishing
3 Thich Nhat Hanh (1990) in Foreword to Kabat-Zinn, 1990 (op cit)
4 Lotus Sutra, Chapter 12. There are many English translations of the Lotus Sutra in English, One of the most beautiful is by Reeves: The Lotus Sutra, A Contemporary Translation of a Buddhist Classic, Gene Reeves, Wisdom Publications,
5 Ud 5.5
6 Lotus Sutra, Chapter 3
7 Kalama Sutta, AN 3.65
8 SN 56.11
9 Teasdale J Consult Clin Psychol. 2002 Apr;70(2):275-87. Metacognitive awareness and prevention of relapse in depression: empirical evidence. Teasdale JD, Moore RG, Hayhurst H, Pope M, Williams S, Segal ZV.
10 Benson, H, et al. (1974) Decreased blood-pressure in pharmacologically treated hypertensive patients who regularly elicited the relaxation response, The Lancet, 303, Issue 7852, 289-291
11 AN V.57
12 Chadwick P, Hughes S, Russell D, Russell I, Dagnan D. Mindfulness groups for distressing voices and paranoia: a replication and randomized feasibility trial, Behav Cogn Psychother. 2009 Jul;37(4):403-12. Epub 2009 Jun 23.
13 Keown, The Nature of Buddhist Ethics. Macmillan/Palgrave, 1992/2001
14 Paul Gilbert, Compassion Focused Therapy, Routledge, 2010
15 Lotus Sutra, Chapter 10
16 Mumonkan, Case 3
17 SN XLV.2